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EIN: ____________

SSA#: ___________

EN Contract Change Form

Please use this form if you wish to request changes to your Employment Network contract. Simply fill in the
applicable information below and submit to MAXIMUS by fax to 703-683-3289. All fields within each
selected section below must be filled out.

• For changes to your corporate status (official name or EIN), please use section Q.
• For changes to banking information, please see section R.

**Please Note: if this form is submitted via email, it must be sent by the named Signatory Authority,
Primary Contact, or Authorized Negotiator identified in your EN RFP/contract. If this form is faxed, it
must be signed by the same.

If you have any questions, please contact the MAXIMUS Ticket to Work office,
TicketServices@YourTickettoWork.com, or toll-free at 866-968-7842 (1-866-YourTicket).

EN Name: ___________________________
EIN: ___________________________
Your Name: ___________________________
(Must be current Sig. Authority, Primary Contact, or Authorized Negotiator)
Title: ___________________________
Signature: ___________________________
Date of Request: ___________________________

Please select the section(s) to which you wish to make changes by putting an “X” on the line. Where
appropriate, select whether you wish to add or delete information.

A. ___ Add, Delete, or Change Doing Business As (DBA) Name
Name: _______________________________ Add [ ] Change [ ] Delete [ ]

B. ___ Use Text Field
Display the following text below your EN name in the EN Directory (270 character maximum):
____________________________________________________________________
____________________________________________________________________

C. ___ Change Mailing Address to ____________________________________________
____________________________________________
____________________________________________

D. ___ Change Actual Address to ____________________________________________
____________________________________________
____________________________________________

MAXIMUS – Ticket to Work P.O. Box 1433 Alexandria, VA 22313-1433
EIN: ____________
SSA#: ___________

E. ___ Change Beneficiary Contact Information to (beneficiary’s will be given this information in order to
contact your EN.):

Contact Name: ________________________________
Phone: (____)______-___________ Toll Free #: (____)_____-_________
Fax: (____)_____ -____________ TTY: (____)____ -_____________
Email: ________________________________________
 Former contact no longer with the organization

F. ___ Change Primary Contact Information to

Contact Name: ________________________________
Phone: (____)______-___________ Toll Free #: (____)_____-_________
Fax: (____)_____ -____________ TTY: (____)____ -_____________
Email: ________________________________________
 Former contact no longer with the organization

G. ___ Change Signatory Authority Contact Information to

Contact Name: ________________________________
Phone: (____)______-___________ Toll Free #: (____)_____-_________
Fax: (____)_____ -____________ TTY: (____)____ -_____________
Email: ________________________________________
 Former contact no longer with the organization

H. ___ Add or Delete Authorized Negotiators

Name: _______________________________________ Add [ ] Delete [ ]

Name: _______________________________________ Add [ ] Delete [ ]

Name: _______________________________________ Add [ ] Delete [ ]

I. ___ Change Payment Contact Information to
(EN-designated contact to receive notices and statements and follow-up inquiries from the Social
Security Administration and the MAXIMUS EN Payment Department)

Contact Name: ________________________________
Phone: (____)______-___________ Toll Free #: (____)_____-_________
Fax: (____)_____ -____________ TTY: (____)____ -_____________
Email: ________________________________________

J. ___ Change Payment Status Report Information to

MAXIMUS – Ticket to Work P.O. Box 1433 Alexandria, VA 22313-1433
EIN: ____________
SSA#: ___________

(EN-designated contact to receive EN Payment Status Report from the MAXIMUS EN
Payment Department. May be different than the EN Payment Information Contact above)

Contact Name: ________________________________
Phone: (____)______-___________ Toll Free #: (____)_____-_________
Fax: (____)_____ -____________ TTY: (____)____ -_____________
Email: ________________________________________

K. ___ Add, Delete, or Change Website
Website Address ____________________________________ Add [ ] Delete [ ]

Do you want a link to this website on the Employment Network Directory? Yes [ ] No [ ]

L. ___ Change Type of Organization to: (check all that apply)

___ Advocacy Group
___ Business/Employer
___ Community Based Organization
___ Education/Training
___ Faith-based Organization
___ Healthcare Provider
___ State/Local Government
___ Transportation/Transit

M. ___ Add or Delete Preferred Impairment Groups Served:

Impairment Group: _______________________________________ Add [ ] Delete [ ]
Impairment Group: _______________________________________ Add [ ] Delete [ ]
Impairment Group: _______________________________________ Add [ ] Delete [ ]
Impairment Group: _______________________________________ Add [ ] Delete [ ]
Impairment Group: _______________________________________ Add [ ] Delete [ ]
Impairment Group: _______________________________________ Add [ ] Delete [ ]
Impairment Group: _______________________________________ Add [ ] Delete [ ]
Impairment Group: _______________________________________ Add [ ] Delete [ ]
Impairment Group: _______________________________________ Add [ ] Delete [ ]

N. ___ Add or Delete Services Offered

Service: _______________________________________ Add [ ] Delete [ ]
Service: _______________________________________ Add [ ] Delete [ ]
Service: _______________________________________ Add [ ] Delete [ ]
Service: _______________________________________ Add [ ] Delete [ ]
Service: _______________________________________ Add [ ] Delete [ ]
Service: _______________________________________ Add [ ] Delete [ ]
Service: _______________________________________ Add [ ] Delete [ ]
Service: _______________________________________ Add [ ] Delete [ ]
Service: _______________________________________ Add [ ] Delete [ ]
MAXIMUS – Ticket to Work P.O. Box 1433 Alexandria, VA 22313-1433
EIN: ____________
SSA#: ___________

O. ___ Add or Delete Service Areas to

___ National (serving all states and US Territories) Add [ ] Delete [ ]
___ Multi-State (list all states you wish to change - you may use the two letter state abbreviation)

State: _______ Add [ ] Delete [ ] State: _______ Add [ ] Delete [ ]
State: _______ Add [ ] Delete [ ] State: _______ Add [ ] Delete [ ]
State: _______ Add [ ] Delete [ ] State: _______ Add [ ] Delete [ ]
State: _______ Add [ ] Delete [ ] State: _______ Add [ ] Delete [ ]

___ Single State (list the state) ___________________________________ Add [ ] Delete [ ]

For each state you are serving, of which you are only serving a selected county(s), please list the
state (using the two letter state abbreviation) followed by the selected county(s) you wish to add or
delete:

State, County: _______________________________ Add [ ] Delete [ ]
State, County: _______________________________ Add [ ] Delete [ ]
State, County: _______________________________ Add [ ] Delete [ ]
State, County: _______________________________ Add [ ] Delete [ ]
State, County: _______________________________ Add [ ] Delete [ ]
State, County: _______________________________ Add [ ] Delete [ ]
State, County: _______________________________ Add [ ] Delete [ ]

For each state you are serving, of which you are NOT serving an entire county(s), please list the
state (using the two letter state abbreviation) followed by the selected zip code(s) you wish to add or
delete:

State, Zip Code: _________ Add [ ] Delete [ ] State, Zip Code: _________ Add [ ] Delete [ ]
State, Zip Code: _________ Add [ ] Delete [ ] State, Zip Code: _________ Add [ ] Delete [ ]
State, Zip Code: _________ Add [ ] Delete [ ] State, Zip Code: _________ Add [ ] Delete [ ]
State, Zip Code: _________ Add [ ] Delete [ ] State, Zip Code: _________ Add [ ] Delete [ ]
State, Zip Code: _________ Add [ ] Delete [ ] State, Zip Code: _________ Add [ ] Delete [ ]
State, Zip Code: _________ Add [ ] Delete [ ] State, Zip Code: _________ Add [ ] Delete [ ]
State, Zip Code: _________ Add [ ] Delete [ ] State, Zip Code: _________ Add [ ] Delete [ ]

P. ___ Add or Delete Service Locations

Location Address: ___________________________________________ Add [ ] Delete [ ]
___________________________________________
___________________________________________

Primary Contact Information:

Contact Name: ________________________________
Phone: (____)______-___________ Toll Free #: (____)_____-_________

MAXIMUS – Ticket to Work P.O. Box 1433 Alexandria, VA 22313-1433
EIN: ____________
SSA#: ___________

Fax: (____)_____ -____________ TTY: (____)____ -_____________
Email: ________________________________________

Beneficiary Contact Information:

Contact Name: ________________________________
Phone: (____)______-___________ Toll Free #: (____)_____-_________
Fax: (____)_____ -____________ TTY: (____)____ -_____________
Email: ________________________________________

Preferred Impairment Groups Served at This Location:

Impairment Group: _______________________________________ Add [ ] Delete [ ]
Impairment Group: _______________________________________ Add [ ] Delete [ ]
Impairment Group: _______________________________________ Add [ ] Delete [ ]
Impairment Group: _______________________________________ Add [ ] Delete [ ]
Impairment Group: _______________________________________ Add [ ] Delete [ ]
Impairment Group: _______________________________________ Add [ ] Delete [ ]
Impairment Group: _______________________________________ Add [ ] Delete [ ]

Services Offered at This Location:

Service: _______________________________________ Add [ ] Delete [ ]
Service: _______________________________________ Add [ ] Delete [ ]
Service: _______________________________________ Add [ ] Delete [ ]
Service: _______________________________________ Add [ ] Delete [ ]
Service: _______________________________________ Add [ ] Delete [ ]
Service: _______________________________________ Add [ ] Delete [ ]
Service: _______________________________________ Add [ ] Delete [ ]
Service: _______________________________________ Add [ ] Delete [ ]
Service: _______________________________________ Add [ ] Delete [ ]

Q. ___ Changes to Your Corporate Status (Official Name or EIN)

Official Organization Name:

Old Organization Name: ___________________________
New Organization Name: ___________________________

EIN Change:

Old EIN: ___________________________
New EIN: ___________________________

MAXIMUS – Ticket to Work P.O. Box 1433 Alexandria, VA 22313-1433
EIN: ____________
SSA#: ___________

R. ___ Changes to Your Banking Information

** Please Note: Changes to your EN’s banking information may only be made by the Signatory
Authority or an Authorized Negotiator listed in your contract. Unlike other contract changes, this
request to change your banking formation must be made via fax or direct mail, and it must include a
new ACH Vendor Payment Form (attached). This ACH form must be signed by a representative
of your bank.

Please complete the following statement, which will serve as your request to change your banking
information:

I ____________ (name), _____________ (title), request that my
Employment Network’s banking information be changed, according to
the information on the attached ACH Vendor Payment Form.

Tips for completing the ACH Vendor Payment Form:

- The ACH form consists of three sections, the first of which, titled “Agency Information” is
already completed.

- The second section, titled Payee/Company Information, is the section in which you should fill
in your EN’s information. In the box labeled “Contact Person Name,” your name should be
both written AND signed.

- The third section, Financial Institution Information, is the section that should be completed
and signed by a representative of your bank.

The information provided by the offeror on this form is for government use only for this requirement, to
facilitate the electronic payment from SSA to the EN contractor and will not be released to entities outside
of MAXIMUS, SSA, or your designated financial institution.

MAXIMUS – Ticket to Work P.O. Box 1433 Alexandria, VA 22313-1433
EIN: ____________
SSA#: ___________

MAXIMUS – Ticket to Work P.O. Box 1433 Alexandria, VA 22313-1433

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